Dialysis Counselling – OSCE Guide

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This article provides a step-by-step approach to counselling patients about dialysis in an OSCE setting, including the information you will be expected to give and how to structure the consultation.

This guide will cover the two main dialysis modalities (haemodialysis and peritoneal dialysis) with their respective advantages and disadvantages.

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Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain the reason for the consultation: “Today I’d like to talk to you about the options for dialysis, would that be okay?”

It is important to establish a good rapport and an open line of communication with the patient early in the consultation: “If you have any questions at any point, or if something is not clear, please feel free to interrupt and ask me.”

Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to ask questions (this is often referred to as ‘chunking and checking’).

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Ideas, concerns and expectations

A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).

Asking about a patient’s ideas, concerns and expectations can provide insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. When several treatment options are available, it is important to explore ICE, as patients may have researched specific treatments. Identifying patient concerns and expectations early in the consultation is key, as this may affect their tolerability and adherence to certain treatment regimens. 

It can sometimes be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three areas below.

Ideas

What is the patient’s knowledge and understanding of dialysis:

• “What do you already know about dialysis?”
• “Have you ever heard of any specific types of dialysis?”
• “Do you know anything about haemodialysis/peritoneal dialysis?”

Concerns

Ask if the patient has any concerns about dialysis:

• “Is there anything that worries you about dialysis?”

Expectations

Explore the patients’ expectations for the consultation:

• “What were you hoping we would cover today regarding dialysis?”
• “Is there a type of dialysis you wanted to focus on?”

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Patient history

Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focused history early in the consultation.

This should include exploring the patient’s condition and reason for requiring dialysis: “Just so we are on the same page, could you tell me a bit about why you need dialysis?”

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What is dialysis?

Using patient-friendly language, explain that dialysis is a form of renal replacement therapy (RRT) used in patients with end-stage renal disease.¹

Usually, healthy kidneys filter the blood by removing waste products and excess fluid, which is then passed as urine.²

Dialysis is an artificial method of removing waste products and managing fluid balance. It replaces part of kidney function but it is not a cure for kidney disease.³ It allows people to live longer, feel better and continue doing the things they enjoy.⁴

“Normally, the kidneys filter the blood, removing harmful waste products and excess fluid. These are then turned to urine and passed out of the body. When the kidneys aren’t working the waste products and excess fluid can no longer be filtered from the blood. To prevent dangerous build-up of toxins, the blood needs to be regularly ‘cleaned’. Dialysis acts as an artificial kidney cleansing your blood during treatment, keeping the body in balance.”

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How does dialysis work?

Explain that dialysis works by passing blood on one side of a semi-permeable membrane with dialysate on the other side. Excess salt, fluid, and waste products move from the blood into the dialysate.^4,5

“Dialysis passes blood on one side of a filter with dialysis fluid on the other. The membranes act as a sieve/colander, filtering waste products and excess water from the blood into the dialysate fluid. The used dialysate fluid is disposed of.”

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What are the types of dialysis?

The two main types of therapy are haemodialysis (HD) and peritoneal dialysis (PD). Haemodialysis is the most common and well-known type of dialysis.¹ Emphasise that both types of dialysis broadly do the same thing, and neither modality of dialysis has been proven to be better.⁴

Continuous renal replacement therapy (CRRT), or haemofiltration, is used in critically ill patients. This is not used in the outpatient setting and will not be discussed further in this article. 

“There are two types of dialysis – haemodialysis and peritoneal dialysis. Both clear the blood of waste products. We will explore which type is best for you, as each has advantages and drawbacks.”

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Haemodialysis

How does haemodialysis work?

Explain to the patient that during haemodialysis, a machine draws blood from their arm via a fistula, a graft, or a line in a large vein and passes it through a dialyser (the “artificial kidney”).

As the blood runs through the dialyser, toxins are filtered, excess water is removed, and clean blood is returned to the body.^3,5 During dialysis sessions, patients usually sit or lie on a recliner chair or couch. During this time, they can watch TV, use electronic devices, read or sleep.⁷

Haemodialysis can be carried out in a dialysis centre or at home. Patients attending a dialysis centre usually dialyse three times a week, each lasting three to four hours.⁸

“Haemodialysis is performed using an external machine. The machine has an artificial kidney called a dialyzer. Blood is drawn from your body into the machine. Your blood is filtered by the machine removing waste and excess water. The filtered blood then passed back into you. This can be done in a dialysis centre or in your own home. In a dialysis centre, you will usually have dialysis three days a week with each session lasting about three to four hours. During dialysis, you can be sitting or lying down on a chair or couch. You can read, watch TV, use your phone or sleep.”

Vascular access

Before haemodialysis treatment can start, there needs to be vascular access (a way of reaching the blood). The preferred method of access is creating an arteriovenous fistula in the arm, which involves a surgical procedure to join an artery and a vein. 

This creates a large blood vessel used as vascular access for the dialysis machine. The surgery is performed at least eight weeks before starting haemodialysis to allow the fistula to mature.

If the patient does not have suitable veins, an artificial graft may need to be inserted. Where there is no sufficient time to form a fistula or graft, or where the patient needs dialysis straight away, a line (usually tunnelled) may need to be inserted into a large vein (normally the jugular).^7,8

“Before you can start haemodialysis, there needs to be some way for you to be connected to the machine so that your blood can flow through the dialyzer. The best way is for you to have an arteriovenous fistula made. This is a surgical procedure where an artery and a vein are connected, usually in the arm. This makes a large blood vessel where blood can be transferred to and from the dialysis machine. The fistula makes dialysis access easier and means blood can flow faster to and from the machine.

The operation will be carried out at least eight weeks before you can start haemodialysis. This allows enough time for the fistula to heal and mature so it can be used safely.

If your veins are not good enough to form a fistula, you may require a graft (artificial vein) to be inserted. If there is insufficient time for the fistula or graft to be performed, or if your blood vessels are not good enough, a line (plastic tube) will be inserted into one of your veins.”

Home dialysis

A patient can be given a simpler dialysis machine to have at home. This dialysis is done more often, usually five to seven days a week, but with shorter sessions. This can also be done at night while the patient sleeps.¹⁰

Advantages of haemodialysis

Giving the patient enough information is important to make an informed decision. Signposting will help you structure this part of the consultation.

“Now, I’d like to talk to you about the advantages and disadvantages of haemodialysis. Is this okay with you?”

Dialysis centres

“There is a social aspect. You will meet other people receiving haemodialysis, which may give you emotional support” ⁷

Performed by healthcare professionals

“Haemodialysis is performed by trained healthcare professionals who will be with you at all times during the treatment” ⁷

Dialysis free days

“Unlike peritoneal dialysis, you do not need to receive dialysis every day. You will have three or four dialysis-free days” ⁹

Home haemodialysis advantages

“It can be flexible, and treatments can be altered to best suit you. Like three to seven short treatments or fewer longer treatments” ¹⁰

Disadvantages of haemodialysis

Restricted fluid intake

“Due to the longer times between treatments, excess fluid can build up, which the dialysis machine may not be able to remove in only four hours. Most people can drink one to one and a half litres of fluid daily. Otherwise, excess fluid can build up in your lungs and tissues” ^{4, 8}

Restricted diet

“As there are longer times between treatment sessions, salt and other minerals (potassium and phosphorus) can build up to dangerous levels” ^{4, 8}

Low blood pressure

“One of the most common side effects of haemodialysis is low blood pressure, you may feel weak, sick or dizzy. This is due to a drop in your fluid levels during dialysis” ¹¹

Risk of infection

“Haemodialysis increases your risk of a life-threatening blood infection called sepsis. Bacteria enter the body and spread through the bloodstream throughout the body, this is very dangerous” ¹¹

Muscle cramps

“Some people can experience muscle cramps during treatment due to sudden changes in the body’s water and chemical balance” ¹¹

Feeling itchy

“Build-up of salts and minerals between dialysis sessions can make your skin feel very itchy” ¹¹

Requires vascular access (fistula, graft or line)

“You will have to have an operation to form a fistula before you can start haemodialysis and take care of it while it heals and between dialysis sessions. Fistulas can sometimes have complications like infection, blood clots and stenosis (narrowing).” ¹²

“If your veins aren’t good enough for a fistula, you may require a different procedure for a graft (artificial vein) to be inserted. If there is insufficient time for a fistula or graft to be formed, or if your blood vessels are not good enough, a line (plastic tube) will be inserted into one of your veins.”

Set schedule & travel

“For treatment in a dialysis centre, you’ll have fixed times slots for dialysis sessions. This must fit your work, responsibilities and childcare duties. After dialysis sessions, you can feel exhausted” ³

“Some hospitals have more than one associated dialysis centre. Travel to and from the facility can mean more time and hassle” ⁷

Home haemodialysis disadvantages¹⁰

“You will need to make space for the dialysis machine and supplies”

“To have home dialysis, you need to have a trained individual/partner/family member at home with you”

“You and your partner/friend/family member will need to undergo training to place needles for access, infection prevention, record treatment details, manage your supplies and operate the dialysis machine.”

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Peritoneal dialysis

How does peritoneal dialysis work?

Explain to the patient that peritoneal dialysis uses the peritoneum (abdominal lining) as a natural filter, with dialysis occurring inside the body. Dialysis fluid is passed into the peritoneal cavity via a catheter. Solutes diffuse from the peritoneal vessels across the peritoneal membrane into the dialysate.^{3, 5}

The used dialysis fluid is subsequently drained and replaced with fresh fluid. Changing fluid takes around twenty to thirty minutes. This can be performed manually around four times per day (continuous ambulatory peritoneal dialysis) or by a machine overnight while the patient sleeps (automated peritoneal dialysis).^{12, 13}

“Peritoneal dialysis uses the lining of your abdomen (the peritoneum) as a natural filter, dialysis will take place inside of the body. A tube called a catheter will be inserted into your abdomen. Through this catheter, the dialysis fluid is passed into your belly. Waste products and excess fluid is drawn from the blood vessels lining the peritoneal cavity into the dialysis fluid. The used fluid is drained and replaced with clean fluid. This process is repeated multiple times. Changing fluid or ‘exchange’ takes twenty to thirty minutes and needs to be repeated multiple times a day, every day. This can be done while you are awake (usually four times per day) or automatically by a machine while you sleep.”

Peritoneal dialysis catheter

Inform the patient that before starting peritoneal dialysis, they must have a small procedure to place a tunnelled peritoneal dialysis catheter. Under local or general anaesthetic, an incision will be made in the skin below the umbilicus, where the catheter is inserted into the abdomen. It then runs under the skin and exits in the left or right flank.^{14, 15}

“Before you can start peritoneal dialysis you will need a small procedure to place a tube known as a catheter. A cut will be made just below your belly button and a catheter will be inserted and then run under the skin exiting in the left or right flank. This catheter will stay in your abdomen permanently. This is so the dialysis fluid can be passed into the space in the abdomen.”

Types of peritoneal dialysis

“Changing the dialysis fluid or ‘doing an exchange’ can be done manually while awake during the day or automatically by a machine overnight while asleep. These are called continuous ambulatory and automated peritoneal dialysis, respectively” ³

Continuous ambulatory peritoneal dialysis (CAPD)

In CAPD, patients constantly have dialysis fluid in their abdomen. The patient will manually perform dialysate exchanges themselves. Each fluid exchange will take around twenty to thirty minutes, with about four daily fluid exchanges.^3,12,15

“You will have dialysis solution in your abdomen at all times. Ambulatory means that you won’t be attached to a machine and will be able to go about your day. You will perform the dialysate fluid exchange yourself. You will need to perform about four exchanges per day, each taking around half an hour.”

Automated peritoneal dialysis (APD)

In APD, the dialysate exchange is ‘automated’ and performed by a machine overnight while the patient is asleep. The patient connects to the machine each night. They need to be attached for around ten hours.^3,12,15

“The peritoneal dialysis will occur overnight. Before you go to bed you attach yourself to a machine that continuously replaces the dialysis fluid while you are sleeping. This will take around ten hours every night.”

Advantages of peritoneal dialysis

Less restriction on diet and fluid intake

“As you have more continuous dialysis treatments, there are fewer restrictions on diet and fluid intake than with haemodialysis”.⁹

Responsibility to manage own care

“You perform peritoneal dialysis yourself”.³

Flexibility of treatment

“Treatment is flexible and can be adjusted to fit in with work, school or travel plans because you are in charge of your own treatment”.^{3, 15}

No needles

“Dialysate is passed in and out via the catheter. There are no needles used during the process.”

Travel and holidays

“With peritoneal dialysis, can be easier to organise travel. You just need to get dialysis fluid delivered to your destination”.^{3, 15}

CAPD advantages

“You do not need a machine to perform dialysate exchanges.”

“With CAPD, exchanges can be varied to fit in with your schedule giving you flexibility with work, school or travel.”

“Exchanges can be performed anywhere you can access hand washing facilities and a cleanable surface like a plastic tray. This portable equipment means you can travel away from home.”

APD advantages

“With APD, no dialysis exchange occurs during the day.”

Disadvantages of peritoneal dialysis

Every day is a dialysis day

“Peritoneal dialysis needs to be carried out every day, there are no dialysis-free days”.⁹

Permanent catheter

“The catheter will be hidden under your clothes, but some people can find it upsetting having a permanent tube in their abdomen”.⁹

“Sometimes there can be problems with the catheter such as infection, blockage, kinking, leaks and displacement”.¹²

Risk of an abdominal infection (peritonitis)

“Peritonitis is an infection of the membrane lining your abdomen called the peritoneum. Peritonitis is very dangerous and potentially life-threatening”.^9,11

Ownership over health and meticulous cleanliness

“To avoid dangerous infection, you must be very clean and always use best practice. Any bacteria left on the dialysis equipment can spread into the abdomen”.^11,15

Thickening and scarring of the peritoneum

“Over several years, the natural filter or peritoneum becomes thickened and scarred. When the peritoneum becomes scarred, it cannot act as a filter, and you may have to switch to haemodialysis”. ^11,12

Weight gain and effect on blood sugars

“The dialysis fluid used in peritoneal dialysis has lots of sugar to help draw out excess water from the blood. Your body absorbs this sugar, significantly increasing your calorie intake, which can result in weight gain. If you are a diabetic, this can cause a rise in blood sugars and make it harder to control your blood sugar levels.”¹¹

Risk of hernia

“Holding lots of fluid inside the abdomen strains your abdominal muscles. A hernia will appear as a lump during coughing, straining or bending over. Usually, this will need to be repaired with surgery.”¹¹

Preventing constipation

Patients should know that constipation can press on the catheter or cause it to move out. This can make it difficult for dialysis fluid to drain.

“It’s important to keep the bowels regularly working during peritoneal dialysis. Constipation can interfere with how fluid drains in and out of your abdomen”.¹⁶

Continuous ambulatory peritoneal dialysis (CAPD) disadvantages

“Having to perform fluid exchanges every four hours can disrupt your daily routine.”

“As it is continuous, you will always have fluid in your abdomen, 24 hours a day, seven days a week.”

Automated peritoneal dialysis APD disadvantages

“You will need to make space for a machine and supplies in your home.”

“Being connected to the machine for eight to ten hours a night can limit your movement.”

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Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the consultation.

Finally, thank the patient for their time and offer them a leaflet summarising the key information related to dialysis modalities (e.g. haemodialysis leaflet, peritoneal dialysis leaflet) 

Dispose of PPE appropriately and wash your hands.

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Summary table

Dialysis type	Haemodialysis	Peritoneal dialysis
What	Diverting blood into an external machine, the blood is filtered before being returned to the body.	Passing dialysis fluid into the abdominal cavity via a permanent catheter. The dialysate draws out waste products from the blood passing through vessels lining the inside of the abdomen.
How	Dialysis centre (or at home). Using a dialysis machine 3 times/week, each session lasts 4 hours.	Performed at home. CAPD: 20-30 minute exchange, 4 times per day APD: Dialysis machine attached to catheter around 10 hours each night
Pros	3-4 dialysis-free days a week Dialysis centres are widely available Socially meet other people undergoing dialysis Performed by healthcare professionals	Less restriction on fluid and diet intake Performed by the patient Flexibility No regular visits to a centre No needles Easier to travel and go on holidays
Cons	Restricted fluid intake Restricted diet Low blood pressure Sepsis Muscle cramps Feeling itchy Surgery to create an AV fistula eight weeks before dialysis can start. Complications associated with an AV fistula Set schedule and planning life around dialysis sessions Travel to the dialysis centre	Must be carried out every day Abdominal catheter Risk of peritonitis (infection of the membrane lining the abdomen) Responsibility for cleanliness and own health Scarring of the peritoneum Weight gain Rise in blood sugars in diabetic patients Hernias

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Reviewer

Dr Mahzuz Karim

Consultant Nephrologist

Norfolk and Norwich University Hospital

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References

1. GOV.UK. Dialysis guidance. 2022. Available from: [LINK]
2. Kidney Patient Guide. Dialysis treatment. 2021. Available from: [LINK]
3. Dialysis overview. 2021. Available from: [LINK]
4. Haemodialysis. 2018. Available from: [LINK]
5. Wilkinson I, Raine T, Wiles K, Goodhart A, Hall C, O’Neill H. Oxford handbook of clinical medicine. 10th ed. Oxford University Press; 2017.
6. Kellum,JA, Bellomo R, Ronco C. Continuous Renal Replacement Therapy. Oxford University Press, 2016.
7. NHS Cambridge University Hospitals. A patients guide to haemodialysis. 2019. Available from: [LINK]
8. NHS.uk Dialysis How it’s performed. 2021. Available from: [LINK]
9. NHS.uk. Dialysis pros and cons. 2021. Available from: [LINK]
10. Home dialysis the advantages. 2019. Available from: [LINK]
11. NHS.uk. Dialysis side effects. 2021. Available from: [LINK]
12. Tidy, C. Renal replacement therapy and transplantation. 2022. Available from: [LINK]
13. Kidney Care UK. Peritoneal dialysis. Available from: [LINK]
14. North Bristol NHS Trust. Peritoneal Dialysis catheter insertion. 2020. Available from: [LINK]
15. NHS Cambridge university hospitals. What I need to know about choosing peritoneal dialysis. 2021. Available from: [LINK]
16. NHS Hull University Teaching Hospitals. Constipation in Kidney disease. 2020. Available from: [LINK]

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